After bone marrow transplant, the daily dose is titrated by the neutrophil response. When the ANC is >1000/mm3 for 3 consecutive days, the dose should be reduced by 5 mcg/kg/day. If the ANC remains >1000/mm3 for 3 or more consecutive days, filgrastim is discontinued. If the ANC decreases to <1000/mm3, filgrastim should be resumed at 5 mcg/kg/day. monitor CBC with differential and platelet count twice weekly during initial 4 wk of therapy and during 2 wk after any dose adjustment.May cause ↓ platelet count and transient ↑ in uric acid, LDH, and alkaline phosphatase concentrations.

-Administration Info

Administer no earlier than 24 hr after cytotoxic chemotherapy, at least 24 hr after bone marrow infusion, and not during the 24 hr before administration of chemotherapy.

Refrigerate; do not freeze. Do not shake. May warm to room temperature for up to 6 hr before injection. Discard if left at room temperature for >6 hr. Vial is for 1-time use only.

SC: If dose requires >1 mL of solution, may be divided into 2 injection sites.May also be administered as a continuous subcut infusion over 24 hr after bone marrow transplantation.

IV Administration

Continuous Infusion: Diluent: Dilute in D5W. Refrigerate; do not freeze. Do not shake. May warm to room temperature for up to 6 hr before injection. Vial is for 1-time use only. Concentration: Dilute to a final concentration of at least 15 mcg/mL. If the final concentration is <15 mcg/mL, human albumin in a concentration of 2 mg/mL must be added to D5W before filgrastim to prevent adsorption of the components of the drug delivery system.

After chemotherapy dose may also be administered as a continuous infusion.

After bone marrow transplant, dose should be administered as an infusion over 4 or 24 hr.

-Family Teaching

Advise female patient to notify health care professional if pregnancy is planned or suspected or if breast feeding. Encourage patients that become pregnant during therapy to enroll in Amgen's Pregnancy Surveillance Program

Home Care Issues: Instruct patient on correct technique and proper disposal for home administration. Caution patient not to reuse needle, vial, or syringe. Provide patient with a puncture-proof container for needle and syringe disposal.

May cause ↑ in WBCs and platelets. May ↓ bleeding times.Monitor serum ferritin, transferrin, and iron levels to assess need for concurrent iron therapy. Transferrin saturation should be at least 20% and ferritin should be at least 100 ng/mL. If ↑ in hemoglobin continues and exceeds 11 g/dL, dose should be withheld until hemoglobin begins to ↓

-Administration Info

IV Admin: Transfusions are still required for severe symptomatic anemia. Supplemental iron should be initiated with epoetin and continued throughout therapy.

Institute seizure precautions in patients who experience greater than a 4-point increase in hematocrit in a 2-wk period or exhibit any change in neurologic status. Risk of seizures is greatest during the first 90 days of therapy.

SC: This route is often used for patients not requiring dialysis.

May be admixed in syringe immediately before administration with 0.9% NaCl with benzyl alcohol 0.9% in a 1:1 ratio to prevent injection site discomfort.

Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy.Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results.Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis.

PO: around the clockIV: Add 10 mL of sterile water for injection without preservatives to 250- or 500-mg vials and 20 mL to 1-g vial. Solution is stable for 7 days after reconstitution if refrigerated.

Continuous Infusion: May also be administered as an infusion over 4 hr. Diluent: 0.9% NaCl, D5W, or LR. Concentration: 1 g/L.

-Family Teaching

Instruct patient to take medication around the clock and to finish the drug completely as directed, even if feeling better. Take missed doses as soon as remembered, with remaining doses evenly spaced throughout day. Advise patient that sharing of this medication may be dangerous.May cause nausea, vomiting, diarrhea, or stomach cramps; notify health care professional if these effects persist or if severe abdominal pain, yellow discoloration of the skin or eyes, darkened urine, pale stools, or unusual tiredness develops. May cause infantile hypertrophic pyloric stenosis in infants; notify health care professional if vomiting and irritability occur.Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional. May occur up to several weeks after discontinuation of medication.Advise patient to report signs of superinfection (black, furry overgrowth on the tongue; vaginal itching or discharge; loose or foul-smelling stools).Instruct patient to notify health care professional if symptoms do not improve.

IV: Reconstitute each vial with 10 mL of 0.9% NaCl. Reconstituted solution is stable for 6 hr at room temperature.

Direct IV: Diluent: Administer undiluted. Concentration: 4 mg/mL.

Rate: Administer over at least 2 min.Intermittent Infusion: Diluent: Dilute further with D5W, 0.9% NaCl, or LR. Concentration: 0.4–0.8 mg/mL. Diluted solution is stable for 24 hr at room temperature.Rate: Administer over 15 min at a rate of <3 mg/min.

-Family Teaching

Instruct patient to take medication as directed for the full course of therapy, even if feeling better.

Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation.Advise patient to report onset of black, tarry stools; diarrhea; or abdominal pain to health care professional promptly.

Cephalasporins

DO NOT USE IN PTS WITH A HISTORY OF SEVERE REACTION TO PENICILLIN!

Each generation has increasing bactericidal activity to break down gram neg bacteria as well as to reach the cerbrospinal fluid. They interfere with BACTERIAL CELL WALL SYNTHESIS and are considered broad-specturm. The Cell weakens, swells, bursts and dies as a result of increased osmotic pressure inside he cell. Increased Cephalosporin resistance is caused by production of beta lactmases.

Cephalosporins penetrate well into most body fluids and the ECF of most tissues, especially when inflammation (which enhances diffusion) is present.

However, the only cephalosporins that reach CSF levels high enough to treat meningitis are

Ceftriaxone

Cefotaxime

Ceftazidime

Cefepime

All cephalosporins penetrate poorly into ICF and the vitreous humor.

Most cephalosporins are excreted primarily in urine, so their doses must be adjusted in patients with renal insufficiency. Cefoperazone and ceftriaxone, which have significant biliary excretion, do not require such dose adjustment.

=> First-generation cephalosporins: These drugs have excellent activity against Gram-positive cocciOral 1st-generation cephalosporins are commonly used for uncomplicated skin and soft-tissue infections, which are usually due to staphylococci and streptococci.

=> Third-generation cephalosporins: These drugs are active against Haemophilus influenzae and some Enterobacteriaceae (eg, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis) that do not produce ampC β-lactamase or extended-spectrum β-lactamase (ESBL). Ceftazidime is also active against Pseudomonas aeruginosa

Contraindications: Cephalosporins are contraindicated in patients who are allergic to them or who have had an anaphylactic reaction to penicillins.

Propofol (Diprivan)

-Class: General Anesthetics

-Indications

Induction of general anesthesia in children >3 yr and adults.

Maintenance of balanced anesthesia when used with other agents in children >2 mo and adults.

Assess respiratory status, pulse, and BP continuously throughout propofol therapy. Frequently causes apnea lasting ≥60 sec. Maintain patent airway and adequate ventilation. Propofol should be used only by individuals experienced in endotracheal intubation, and equipment for this procedure should be readily available.Assess level of sedation and level of consciousness throughout and following administration.

When using for ICU sedation, wake-up and assessment of CNS function should be done daily during maintenance to determine minimum dose required for sedation

Direct IV: Diluent: Usually administered undiluted. If dilution is necessary, use only D5W. Shake well before use. Solution is opaque, making detection of contaminants difficult. Do not use if separation of the emulsion is evident. Contains no preservatives; maintain sterile technique and administer immediately after preparation.

Concentration: Undiluted: 10 mg/mL. If dilution is necessary, dilute to concentration ≥2 mg/mL.Discard unused portions and IV lines at the end of anesthetic procedure or within 6 hr. For ICU sedation, discard after 12 hr if administered directly from vial or after 6 hr if transferred to a syringe or other container. Do not administer via filter <5–micron pore size.Aseptic technique is essential. Solution is capable of rapid growth of bacterial contaminants. Infections and subsequent deaths have been reported.

Rate: Administer over 3–5 min. Titrate to desired level of sedation. Frequently causes pain, burning, and stinging at injection site; use larger veins of the forearm, antecubital fossa, or a dedicated IV catheter.

Lidocaine 10–20 mg IV may be administered prior to injection to minimize pain. Pedi: Induction doses may be administered over 20–30 seconds.

-Family Teaching

Inform patient that this medication will decrease mental recall of the procedure.May cause drowsiness or dizziness. Advise patient to request assistance prior to ambulation and transfer and to avoid driving or other activities requiring alertness for 24 hr following administration.Advise patient to avoid alcohol or other CNS depressants without the advice of a health care professional for 24 hr following administration.

=> Administration: SubCutaneous tissue, . Alternate injection sites daily between the left and right anterolateral and left and right posterolateral abdominal wall. Inject entire length of needle at a 45° or 90° angle into a skin fold held between thumb and forefinger; hold skin fold throughout injection. Do not aspirate or massage. Rotate sites frequently. Do not administer IM because of danger of hematoma formation. Solution should be clear, colorless to pale yellow; do not inject solution containing particulate matter.

=> Family teaching: Don't take aspirin, Naproxen or ibuprofen without consulting a doctor. Report any signs of bleeding/bruising

NOTE: Double check that pt isn't already receiving Heparin.

Injections should always be 2 inches from umbilicus or any incisional area.

Glucocorticoids cause immunosuppression and may mask symptoms of infection. Instruct patient to avoid people with known contagious illnesses and to report possible infections immediately

.Long-term Therapy: Encourage patient to eat a diet high in protein, calcium, and potassium, and low in sodium and carbohydrates (see food sources for specific nutrients). Alcohol should be avoided during therapy.

=> DIG TOXICITY:*Digoxin will slow down the heart rate but increase contractility* The major point to remember about digoxin is that the therapeutic window is very narrow from 0.5-2.0ng/mL. Over 2.0ng/mL you will see signs of digoxin toxicity:

-can be administered with intermediate or long acting (Due to the short duration of action, insulin lispro must be used with a longer acting insulin, insulin infusion pump or in combination with oral sulfonurea agents.)

-can be administered with intermediate or long acting (Due to the short duration of action, insulin lispro must be used with a longer acting insulin, insulin infusion pump or in combination with oral sulfonurea agents.)

=> Assess:Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Dose may need to be decreased by 25–50%. Initial drowsiness will diminish with continued use.

-Bowel functions (constipation can be avoided with increased fluids/lax)

- Action: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression ( agonist activity at the receptor site can result in alalgesisa, eulphoria, depression, hallucinations,, miosis, and sedation)

do not take with food (slows absorption); can take 1 hour before meals or 2 hours after meals

do not take with iron preps or antacids (slows absorption)

can take with Probenecid (a gout medication) - enhances benefits of fluoroquinolones

==================

Fluoroquinolones (Class)

- Fights UTIs, URIs, GIs and soft tissue infections

-CIPRO NEEDS TO BE INFUSED OVER 60 MINS. Monitor PT times for patients with vanco.

-Watch for photosensitivity, no milk products, iron, zinc, mg and aluminum antacids 6 hours BEFORE and 2 hours AFTER ingestions

-Be careful in kids: can cause tendinitis or tendon rupture and in adult sover 60. Watch for C Diff.

Action: Bactericidal; inhbiits DNA enzyme that interferes with replication; is considered broad spectrum against most ram negative and some gram positive bacteria, not not against anaerobic infections

Contraindications: Hypersensitivity, h/o myastenia gravis, Avoid in children and pregnant

Clindamycin Cleocin (clindamycin)

=> Class: anti-infectives

=> Purpose:-Inhibits protein synthesis in susceptible bacteria at the level of the 50S ribosome.Active against most gram-positive aerobic cocci, including:Staphylococci,Streptococcus pneumoniae,other streptococci, but not enterococci.

-Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy; Obtain specimens for culture and sensitivity prior to initiating therapy. First dose may be given before receiving results.-Monitor bowel elimination. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to HCP promptly as a sign of pseudomembranous colitis.-Assess patient for hypersensitivity (skin rash, urticaria).

-Indications Prevention of nausea and vomiting associated with highly or moderately emetogenic chemotherapy.PO: Prevention of nausea and vomiting associated with radiation therapy.Prevention and treatment of postoperative nausea and vomiting.

-Action

Blocks the effects of serotonin at 5-HT3–receptor sites (selective antagonist) located in vagal nerve terminals and the chemoreceptor trigger zone in the CNS.

Therapeutic Effect(s): Decreased incidence and severity of nausea and vomiting following chemotherapy or surgery.

PO: For orally disintegrating tablets, do not attempt to push through foil backing; with dry hands, peel back backing and remove tablet. Immediately place tablet on tongue; tablet will dissolve in seconds, then swallow with saliva. Administration of liquid is not necessary.

IV Administration

Direct IV: Administer undiluted (2 mg/mL) immediately before induction of anesthesia or postoperatively if nausea and vomiting occur shortly after surgery.Rate: Administer over at least 30 sec and preferably over 2–5 min.

Intermittent Infusion: Diluent: Dilute doses for prevention of nausea and vomiting associated with chemotherapy in 50 mL of D5W, 0.9% NaCl, D5/0.9% NaCl, D5/0.45% NaCl. Solution is clear and colorless. Stable for 7 days at room temperature following dilution.

Concentration: 1 mg/mL.

Rate: Administer each dose over 15 min.

-Patient/Family Teaching

Instruct patient to take ondansetron as directed.Advise patient to notify health care professional immediately if symptoms of irregular heart beat or involuntary movement of eyes, face, or limbs occur.

Potassium (Intermittent Infusion)

Potassium is never given by intravenous (IV) push or by the intramuscular or subcutaneous route.

A dilution of no more than 1 mEq/10 mL of solution is recommended (MUST ALWAYS BE DILUTED!)

After adding potassium to an IV solution, rotate and invert the bag to ensure that the potassium is distributed evenly throughout the IV solution.

Ensure that the IV bag containing potassium is properly labeled.

The maximum recommended infusion rate is 5 to 10mEq/hr, never to exceed 20 mEq/hr under any circumstances.

A client receiving more than 10 mEq/hr should be placed on a cardiac monitor and monitored for cardiac changes, and the infusion should be controlled by an infusion device.

Potassium infusion can cause phlebitis; therefore thenurse should assess the IV site frequently for signs of phlebitis or infiltration. If either occurs, the infusionshould be stopped immediately.

The nurse should assess renal function before administering potassium, and monitor intake and output during administration.

-Evaluates how well the coagulation sequence (intrinsinc clotting system is function my measuring the amount of time ti takes in seconds for recalcified citrated plasma to clot after partial thromboplastin is added to it.

-This test screens for deficiencies and inhitors of all factors, except factors 7 and 13.

-Usually used to montiro the effectiveness of heparin therapy and screen for cagulation disorders

=> Value: 20-36 seconds; when receiving hep therapy, aPTT should be between 1.5-2.5